Preprocedural management of patients with cardiovascular disease

Cao, 2021Duceppe, 2017Fleisher, 2014

In this topic, the term ‘procedure’ refers to any operation or procedure.

All procedures cause a stress response in the body due to tissue injury. The stress response can increase myocardial oxygen demand and affect the balance of fibrinolytic and prothrombotic factors, increasing the risk of cardiac complications in the periprocedural period. Patients with cardiovascular disease, particularly unstable disease, are at further increased risk and require careful management to minimise morbidity and mortality.

Before performing a procedure in a patient with cardiovascular disease, assess the risk of periprocedural cardiac complications. Consult the patient’s general practitioner and specialist(s) about current diagnoses, functional status and drug therapy, and history of cardiovascular events and cardiac procedures. Consider the risk versus the expected benefit of the procedure. Referral to a physician specialising in periprocedural assessment may be appropriate, particularly for complex patients. Many procedures (such as breast, plastic, and orthopaedic surgeries) carry a low risk of cardiac events and usually do not need major preprocedural investigation in stable patientsHalvorsen, 2022.

The following preprocedural measures can improve the patient’s postprocedural outcomes:

• Encourage and assist patients to stop or reduce smoking at least 4 weeks before an operationHalvorsen, 2022. Benefits of smoking cessation include improved wound healing after 3 weeks, reduced sputum volume and improved lung function after 8 weeks, and improved immune function after 6 months (see Harms of tobacco smoking and nicotine dependence and benefits of intervention for a comprehensive list of health benefits associated with smoking cessation or reduction).
• Optimise drug therapy to achieve good control of atherosclerotic cardiovascular risk factors (including blood pressure, dyslipidaemia and diabetes), angina, heart failure and cardiac rhythmHalvorsen, 2022.
• Investigate any symptoms and manage previously undiagnosed conditions identified during preprocedural assessment (eg chest pain, shortness of breath, cardiac murmurs, arrhythmias)Cao, 2021.
• Continue most cardiac drugs up to the day of the procedure; consult the proceduralist and the anaesthetist to determine if any drugs should be withheld on the morning of the procedure.
• Consider withholding sodium-glucose co-transporter 2 (SGLT2) inhibitor therapy (eg dapagliflozin, empagliflozin, ertugliflozin) as these drugs have been associated with ketoacidosis (with or without accompanying hyperglycaemia)Halvorsen, 2022. The risk is increased during the perioperative period, when prolonged fasting and decreased carbohydrate intake are common—see Sodium-glucose co-transporter 2 inhibitors for more information on the periprocedural management of SGLT2 inhibitors.
• Only interrupt antithrombotic therapy if this is required to reduce the periprocedural bleeding risk (see General principles of periprocedural management of antithrombotic therapy).
• Plan venous thromboembolism prophylaxis if indicated.
• Give antibiotics for the prevention of infective endocarditis if indicated.
• Plan periprocedural management of cardiac implanted electronic devices (CIED), including pacemakers and implantable cardioverter defibrillators (ICD), if needed.

For general information on the periprocedural management of patients with type 1 or type 2 diabetes, see Periprocedural management of adults with diabetes.

Investigation with stress testing or echocardiography in an asymptomatic patient is unnecessary and is not recommendedHalvorsen, 2022Smilowitz, 2020. Routine revascularisation (by surgery or percutaneous coronary intervention) without a specific indication (eg ongoing chest pain) is not recommended, as it does not reduce periprocedural cardiac events.

Routine preprocedural initiation of a beta blocker is unlikely to reduce surgical mortality and is not recommended. Continue existing beta-blocker therapy in patients with an indication for treatmentHalvorsen, 2022.

In the absence of an indication, adding aspirin, an angiotensin converting enzyme inhibitor (ACEI), clonidine or a statin to the patient’s existing therapy has not been shown to reduce periprocedural morbidity or mortality, and is not recommendedHalvorsen, 2022.

For detailed discussion of perioperative cardiovascular risk assessment and management for noncardiac surgery, including the use of validated risk indices, see the European Society of Cardiology Guidelines on cardiovascular assessment and management of patients undergoing noncardiac surgery.